Purpose We analyzed closed civil legal cases in 2007-2016 from the Canadian Medical Protective Association (CMPA) involving specialist anesthesiologists where airway management was the central concern. Methods We included all airway-related civil legal cases involving specialist anesthesiologists that closed from 2007 to 2016. The following variables were abstracted by CMPA medical analysts: clinical context, peer expert opinions of contributing factors, and patient and legal outcomes. Results We found 46 of the 406 (11%) closed cases involving anesthesiologists to be airway-related. Twenty-six cases (57%) involved elective surgery and 31 patients (67%) were categorized as American Society of Anesthesiologists physical status III. Twenty-five cases (54%) occurred outside the operating room (e.g., postanesthesia care unit, intensive care unit, or other satellite locations). In 19 (42%) cases, there was at least one predictor of a difficult airway. Peer experts identified judgement failures in 30 cases (65%), most commonly inadequate airway evaluation. In 30 cases (65%), the patient died or had a permanent brain injury. The medicolegal outcome favoured the patient in 27 (59%) cases, with a median [interquartile range] payment of 422,845 [257,637-935,673] CAD. Conclusions Severe patient harm is common when airway management is the focus of a CMPA medicolegal complaint involving anesthesiologists. Patients were otherwise typically low risk cases presenting for elective surgery. Failure to assess or to change management based on the airway exam or encountered difficulty were the most common errors. Our findings support the continued need for adoption, adherence, and practice of guidelines for anticipated and unanticipated difficult airway management for every patient encounter.
F ET. O 2 ) of ≥ 90% is recommended. Preoxygenation is typically carried out using a tight-fitting facemask with 100% inspired oxygen fraction (FiO 2 ) at a flow rate of 10 L/ min, with 3 to 5 minutes of tidal breathing. As obstetrical intubation often requires prompt induction, alternative preoxygenation methods are being explored.A recent study used high-flow nasal oxygen for preoxygenation for term pregnant women. The study had an up-down sequential allocation design, so the predetermined number of VC breaths used for oxygenation differed for each participant, depending on the previous participant. The number of VC breaths needed to achieve F ET O 2 ≥ 90% was the primary outcome. The study was ended early after collecting data for 20 participants because authors believed the primary outcome could not be achieved in most patients. Successful preoxygenation was achieved in 4 participants receiving HFNO with mouth closed, 3 participants using HFNO with mouth open, and 14 using oxygen facemask.The study only considered the efficacy of achieving F ET O 2 ≥ 90%, but not the efficiency of preoxygenation, meant to prolong the "safe apnea" period, of HFNO. In patients undergoing rapid sequence induction, continued HFNO between the time of neuromuscular blockade to intubation, or "peroxygenation," can improve safety. The efficiency of HFNO has not been studied in pregnant patients due to ethical limitations, but a study by Wong et al, in morbidly obese patients undergoing bariatic surgery found a significant increase in the safe apnea time period in patients who used HFNO compared with standard preoxygenation with a facemask.Multiple studies have found achieving F ET O 2 ≥ 90% in pregnant patients to be challenging. While HFNO may not have a high efficacy, there is evidence from other patient populations that it can provide ongoing apneic oxygenation. Clinicians may need to move forward with the use of HFNO during RSI without reassuring trial data, perhaps by using a tight-fitting facemask combined with HFNO.
Background: To enhance patient safety and prevent medico-legal complaints, we need to understand current trends and impacts. We aimed to characterize Canadian plastic surgery medico-legal patterns in many dimensions. Method: This retrospective descriptive analysis of Canadian Medical Protective Association data between January 1, 2013 and December 31, 2017 included closed regulatory body complaints and civil-legal actions involving plastic surgeons. We excluded class action legal cases and hospital complaints. We collected data on patient allegations, procedure types, healthcare-related patient harms, and peer expert criticisms. The primary outcome of interest was physician medico-legal outcome. Results: We found 414 cases that met the inclusion criteria: 253 (61.1%) cases involved cosmetic procedures and 161 (38.9%) noncosmetic procedures. The annual incidence among plastic surgeon members of regulatory body complaints and civil-legal actions was 12.1% and 6.7%, for a combined incidence of 18.8%. The most common allegations were deficient clinical assessment, inadequate informed consent, delayed or misdiagnosis, and inadequate monitoring. Leading contributing factors were physician–patient communication breakdown, deficient clinical judgments, and inadequate documentation. The top procedural complications included cosmetic deformity, poor scarring, upper extremity stiffness or deficit, major structural injury, and mental health disorder. Less than half of cases (198/414, 47.8%) had unfavorable medico-legal outcomes for the surgeon. Patients were compensated in 86/198 (43.4%) of civil-legal cases. Conclusions: Plastic surgeons experience more medico-legal complaints for cosmetic versus noncosmetic procedures. To minimize medico-legal risks, plastic surgeons should focus on strong physician–patient communication, patient education/consent, thorough clinical assessment, minimizing potentially preventable complications, and maintaining relevant documentation.
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